Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20663AI (08/2008)

STATE OF WISCONSIN

ADULT-AT-RISK ABUSE, NEGLECT, AND / OR EXPLOITATION CODE SHEET
SECTION A: INITIAL INFORMATION
Primary Reason for Call (use also for Other Reasons for Call)
1 2 3 4 5 9 10 12 14 15 6 16 17 18 50 19 41 20 21 22 59 60 28 29 61 62 30 31 32 33 51 23 24 10 1 11 12 2 10 1 2 11 3 12 8 4 13 14 Physical Abuse Abrasions, cuts, punctures, bites Beating Bone fracture Bruises, welts Burns, scalding Freezing Internal injuries Pain, no physical marks Skull fracture Sprains, dislocations Strangling Other physical abuse (specify) Neglect by Other(s) Medical needs Medication Nutritional needs Physical needs Psychiatric needs Supervision Unsafe, unsanitary environment Other neglect (specify) Self-Neglect Hoarding (animal) Hoarding (non-animal) Medical needs Medication Mismanaging basic financial activities Nutritional needs Physical needs Supervision Unsafe, unsanitary environment Other self-neglect (specify) Financial Exploitation Computer crimes Deception Diverting income Place of employment/day services Place of residence School Transportation Other (specify) Aging & Disability Resource Center/ Aging Unit Alleged abuser Anonymous Employer Friend/neighbor Housing inspection/zoning Law enforcement Medical professional Mental health service provider Regulatory authority (DHS/DQA) 52 53 54 55 Embezzlement Financial transaction card crimes Forgery or fraudulent writings Misappropriation of personally identifiable information/documents 25 Mismanagement of property 56 Security fraud 57 Substantial failure or neglect of a fiscal agent to fulfill his/her responsibilities 58 Theft by fraud 26 Theft from a person 27 Other financial exploitation (specify) Treatment without Consent 81 Administration of medication to an individual who has not provided informed consent 82 Experimental research on an individual who has not provided informed consent 83 Performance of electroconvulsive therapy on an individual who has not provided informed consent 84 Performance of psychosurgery on an individual who has not provided informed consent 85 Other treatment without consent (specify) Unreasonable Confinement or Restraint 86 Intentional and unreasonable confinement of an individual in a locked room 87 Involuntary separation of an individual from his/her living area 88 Provision of unnecessary or excessive medication to an individual Relative Residential support provider Substance abuse service provider Victim Vocational/day support provider Other provider (specify) Other referral source (specify) Aging & Disability Resource Center/ Aging Unit Animal control/Humane Society Department of Community Programs (51.42/437) Developmental Disability Board Disability Rights Wisconsin (Wisconsin Coalition for Advocacy) Housing inspection/zoning Human services department Institution Nursing home Own home/apartment alone Own home/apartment with others Relative's home Other (specify) 89 90 Use of physical restraining devices on an individual Other unreasonable confinement (specify) Emotional Abuse Demeaning statements Harassment Isolating person from family, friends Threats, intimidation, frightening Other emotional abuse (specify) Sexual Abuse Digital penetration of vagina or anus Exhibitionism Exposure of victim's buttocks, breast, genitalia to humiliate/embarrass Harmful genital practices (not for the benefit of the adult-at-risk) Oral genital contact Prostitution of victim Rape (anal) Rape (vaginal) Rape (vaginal/anal rape with object) Sadistic sexual activity Sexual jokes and comments Sexualized kissing Showing victim pornography Unwelcome description or discussion of sexual topics or threats Unwelcome sexual interest in victim's body Using alleged victim to produce pornography Voyeuristic activity Unknown Other sexual abuse (specify) Other Reason Information only Law enforcement Ombudsman (BOALTC) Regulatory authority (DHS/DQA) Social services department Other (specify) Aging & Disability Resource Center/ Aging Unit Department of Community Programs (51.42/437) Developmental Disability Board Human services department Law enforcement Ombudsman (BOALTC) Regulatory authority (DHS/DQA) Social services department WI Department of Justice Other (specify) Challenging/dangerous behavior Communication disorder Deaf/hard of hearing Developmentally disabled Diabetic Drug abuse Incontinent Limited English proficiency Medically fragile Mental health disorder Mobility impaired

34 35 36 37 38 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 39
70

Incident Location

5 15 16 6 17 18 9 5 10 3 11 12 13 4 11 6 1 2 3 9

2 14 15 7 8 5

Initial Response Agency
3 20 4 21 1 22 7 23 10 77 C1 79 23 C2 5 72 C3 37 2 9

Referral Source

Call Received by

SECTION B: ADULT-AT-RISK INFORMATION
Race (use also for Alleged Abuser)
1 2 3 5 6 7 5 4 8 American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Adult family home or CBRF Friend's home Homeless

Characteristics (Adult-at-Risk & Alleged Abuser)
4 18 7 34 Alcohol abuse Alzheimer's or related dementia Blind/visually impaired Brain injury

Living Arrangement

More Characteristics on next page

F-20663AI

Page 2

SECTION B: ADULT-AT-RISK INFORMATION (cont'd)
Characteristics (Cont'd)
C4 9 C5 Morbidly obese Physically disabled Unemployed C6 C7 C8 Alleged abuser financially dependent on Adult-at-Risk Adult-at-Risk financially dependent on alleged abuser Other physical disability (specify) Sibling Other relative (specify) Roommate Friend/neighbor Employer Vocational/day service provider Referral/Caregiver Misconduct Registry/DQA Referral/law enforcement/Dept. of Justice Referral/detoxification services Referral/protection/advocacy agencies Referral/regulatory authority/DQA C9 88 99 Other medical condition (specify) Other (specify) None

SECTION C: ALLEGED ABUSER INFORMATION
Alleged Abuser's Relationship
2 12 3 4 13 Spouse Parent Daughter Son Grandchild 5 6 14 8 15 16 14 15 16 17 18 S6 9 17 18 10 11 Residential service provider Transportation provider Other service provider (specify) Other (specify) Unknown

SECTION D: REPORT SUMMARY
Action Taken
2 3 4 5 6 7 Response/investigation continues Services not needed Services offered but not accepted Services offered--some accepted Services offered--all accepted Services needed are not available (specify) 19 20 9 10 11 12 13 Referral/other agency (specify) Referral made to state agency Guardian referral Protective services/placement Mental health commitment Other legal action (specify) Other disposition (specify)

Services Planned (Adult-at-Risk and Alleged Abuser)
Advocacy/Legal Services Advocacy & defense resources Attorney (Agency) Attorney (Attorney General's Office) 605.3 Attorney (County Corporation Counsel) 605.4 Attorney (District Attorney's Office) 605.5 Attorney (private) 605.6 Benefit specialist services 301 Court intake and studies 605.7 Law enforcement 406 Protective services/placement 605.9 Temporary restraining order/ restraining order 605.10 Other legal services (specify) Community-Based Aids, Services 112.57 Adaptive aids--vehicle 112.99 Adaptive aids--other 112 Assistive technology 104.24 Chore svcs--major (dumpster, exterminator) 104.23 Chore svcs--routine (sweep, mop, vacuum) 112.47 Communication aids S1 Companion animal assistance/ rehoming 401 Congregate meals 112.58 Durable medical equipment 106.01 Energy assistance 402 Home delivered meals 112.56 Home modifications 106.02 Housing assistance 106.03 Housing startup 112 Interpreter services 104.11 Personal care 103 Respite care (in adult day care) 103 Respite care (other) 112.55 Specialized medical supplies 104 Supportive home care services Other services (specify) Emergency Response Services S2 Client supply/misc. services (specify) 501 Crisis intervention 703 Detoxification services S3 Emergency funds for clothing S4 Emergency funds for food S5 Emergency funds for medical needs 605 605.1 605.2 Emergency funds for transportation 112.46 Personal Emergency Response System 205 Shelter care S7 Other services (specify) Facility-Based Care 202 Adult Family Home (certified) 202 Adult Family Home (licensed) 506 Community-Based Residential Facility (CBRF) 503 Inpatient--Alcohol/Drug 503 Inpatient--Medical 503 Inpatient--Psychiatric 925 Institution for Mental Disease (IMD) 505.2 Intermediate Care Facility for People with Mental Retardation (ICF/MR) 505.1 Nursing Home 711 Residential Care Apartment Complex (RCAC) Other services (specify) Medical Services 105 Home health care agency 105.20 Nursing services 507.12 Occupational therapy (in all settings except inpatient hospital) 507.11 Physical therapy (in all settings except inpatient hospital) 507.13 Speech and language pathology services Other services (specify) Day Care Services/Treatment 102 Adult day care 507.18 AODA day treatment 507 AODA outpatient services 113 Consumer education & training 509 Community Support Program 507 Counseling/therapeutic services 110 Daily living skills training 108.2 Day Svcs/Adult (sheltered workshop) 619 Financial management 507 Medical outpatient care 704 Mental health day treatment 507 Mental health outpatient services 908.57 Peer counseling 108 Prevocational services 403 Recreation/alternative activities 908 Support group 615 Supported employment Other services (specify) Service Coordination Case Management (including assessment & care planning) Consumer-directed supports Housing counseling Information and referral Outreach Relocation services Vocational futures planning Other (specify) Substitute Decision-Making Conservatorship Guardian of the Estate Guardian of the Person Power of Atty--Finances/ Activated Power of Atty--Finances/Not Activated Power of Atty--Health Care/ Activated Power of Atty--Health Care/ Not Activated Representative Payee Program Temporary guardianship Other (specify) Transportation Escort services Transportation Other (specify) Victim Services Domestic violence victim services including shelter and advocacy Sexual assault/abuse victim services including counseling, support services Victim/Witness Program Other services (specify) Other Codes Other direct services (specify) None

604 609 610 602 601 S8 114

S9 S10 S11 S12 S13 S14 S15 S16 S17 S18 107 107 S19 S20 S21

S22 S23 S24 S25